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Licensing Michigan Midwives

The Friends of Michigan Midwives (FoMM) and its parent organization, the Coalition to License CPMs, support licensure based on the Certified Professional Midwife credential for direct entry midwives who attend out-of-hospital births in Michigan. This FAQ addresses questions asked by families and midwives about the recently enacted Michigan licensure measure, House Bill 4598, now Public Act 417 of 2016.February 2017 update: On January 3, 2017, Governor Snyder signed HB 4598 into law. The FoMM FAQ below will soon be updated to explain the law’s provisions and the process for implementing them. FoMM thanks all our supporters for their invaluable help during the last six years!

ANSWERS FOR MOTHERS AND THEIR FAMILIES

Q: Why should the state license midwives?
A: Licensure can help mothers identify qualified midwives. Because licensure requires that midwives attain certain standard qualifications, women seeking midwife services will be able to know which midwives possess these qualifications to provide safe and competent care. The Michigan Constitution requires the state to legislate and regulate when it is necessary to protect public health and safety; safe midwifery care falls under this power.

Q: Why should mothers care if midwives are licensed?
A: Your freedom to give birth at home with a midwife is at stake. Right now, the only midwives allowed under Michigan law to attend out-of-hospital births are Certified Nurse-Midwives. Unfortunately, very few CNMs do so. Although the state has not traditionally prosecuted other midwives, they are nevertheless violating the public health code. Regardless of what state courts may have held in the distant past before the current version of the public health code, Michigan midwives are putting themselves at risk every time they attend a birth or transport a patient. We have seen midwives interrogated by law enforcement, and we have heard voices calling for the public to report midwives to local prosecutors. In other words, your midwife can be arrested at any time.

Q: But Michigan prosecutors have always turned a blind eye to unlicensed midwives’ practices. Why would this change?
A: We have seen other states with similar accommodating environments – for example, Illinois – turn on a dime. Where midwives once were able to practice openly, they are now underground. We want our midwives, and we want them to provide safe, affordable, and accountable care. This is not possible when they are operating without support of the law.

Q: Won’t this push for licensure itself bring midwives to the attention of prosecutors?
A: NO. Prosecutors already know that midwives are practicing. In fact, active licensure legislation is the best possible protection against prosecution, because prosecutors will not prioritize the pursuit of midwives when it is obvious the legislature is trying to address the problem.

Q: What other advantages would licensure provide?
A: Better integration with the medical system and better access. Women and their families will have smoother access to lab work, mainstream medical care, and urgent or emergency treatment. Some families who will not choose midwifery care now may be more likely to do so if midwives are licensed.

Q: My midwife does not wish to be licensed. Will she still be able to practice?
A: Not legally. Once instituted, licensure will be required for anyone wishing to practice midwifery in Michigan. However, the bill as it is now written contains two broad religious exemptions. In addition, some midwives will probably choose to practice in violation of the law; those midwives and their clients may choose to take their chances, just as all midwives and their clients do now.

Q: Will licensure impose costs on my midwife, forcing her to raise her fees?
A: It may, but we think the increase will be nominal. Although not yet finalized, the initial licensing fee is set at $450, with an annual renewal fee of $200. Michigan law requires all licensure regimes to pay for themselves through fees; because there are so few midwives compared to other health care professions, licensure fees were initially determined to be in the thousands of dollars! The state licensing agency, the Department of Licensing and Regulatory Affairs (LARA), worked hard to reduce fees to the amounts listed above.

Fees are partially determined by the state’s costs in assessing midwives’ qualifications. Basing licensure on the CPM credential helps to reduce the cost of licenses: because the North American Registry of Midwives assesses CPMs’ qualifications, the state need not assume that cost, thereby making licenses considerably less expensive. Older laws in other states, especially laws that pre-date the CPM credential, have tended to be more costly than programs enacted in the last decade.

Licensure also has the potential to increase insurance coverage of midwives’ fees, allowing more women to access midwives and allowing midwives to extend care to a wider pool of clients. Medicaid now reimburses licensed midwives in other states for birth center services. Michigan Medicaid will not cover CPM out-of-hospital services until midwives can be licensed. The Harkin Amendment, a clause of the Affordable Care Act, prohibits discrimination by private insurers against classes of providers licensed by a particular state; when regulations are written for this clause, private insurance will be compelled to reimburse licensed CPMs.

Q: My midwife is the only provider willing to attend a VBAC. Will the licensure bill prevent her from doing so?
A: We are strongly advocating to keep all such options open. The intent of the bill is to increase and expand birth options and access to midwives. The way to do this is not to keep midwives unlicensed, but to stand up for these options. We are determined to keep out of the bill any restrictions on procedures that are informed by rapidly changing scientific data. VBAC is a prime example, having been unknown in mainstream medicine for most of the 20th century, strongly encouraged in the 1980s and 90s, and all but forbidden since then. Provisions for such options belong in rules (regulations), written by the Department of Licensing and Regulatory Affairs in consultation with the Board of Midwifery after passage of the bill. When proposed rules are opened to public comment, home birth families, VBAC moms, ICAN, and midwives should be prepared to unite to make sure the state understands that consumers oppose limiting these birth options.

Q: Will licensure require my midwife to carry out prenatal and newborn testing and to administer Vitamin K injections, the Hepatitis B vaccine, and prophylactic eyedrops?
A: NO. Even if midwives are ultimately required by law to offer these testing or treatment options, parents will continue to retain the rights of informed consent and refusal regarding their own and their baby’s care. Currently, physicans are required by law only to administer prophylactic eyedrops.

Q: Will the licensure bill force my midwife to purchase costly malpractice insurance?
A: NO, for several reasons. Malpractice liability insurance requirements cannot be included in a licensure bill, as per LARA. No other Michigan health care profession is required by law to carry malpractice liability insurance; such requirements are typically imposed by employers or group practices.

Q: Wasn’t there another bill to regulate midwifery? Didn’t it include nurse-midwives as well as CPMs?
A: It did, but that bill is history! It was introduced in 2012 and was not supported by FoMM. It has not been re-introduced.

Q: What can I do to help?
A: Sign up on our Advocate web page and check our public Facebook page for advocacy opportunities. A host of volunteer opportunities are available, from contacting your legislators, to attending fundraisers, to working on election campaigns for licensure-supportive candidates.

ANSWERS FOR MIDWIVES

Q: Will licensure limit my practice? Will I be restricted from accepting VBACs? Will the decision when I should transfer care be made by someone else?
A: Licensure by definition imposes standards and sets scope of practice. However, the licensure bill is modeled on laws in states where midwives and clients are free to make informed decisions about these issues, where midwives’ practice is evidence-based, and where the law is written to preserve the midwifery model of care.
Rep. Ed McBroom, sponsor of HB 4598, is strongly anti-regulation in philosophy; yet his work for this bill is motivated by a desire to even the playing field between currently licensed professions and unlicensed midwives.Limits on VBAC – if any – are best located in administrative rules, not statute. Evidence on best practices for VBAC has shifted over time. Administrative rules, which are more easily changed than statutes to accommodate evolving scientific opinion, are the appropriate place to address such issues.
Wisconsin midwives, specialists in low-risk birth, may attend home births considered to have risk factors if midwives possess the skill and experience, and have assembled a good team and a collaborative provider. This is Michigan’s goal too, to be achieved through the public notice-and-comment process for administrative rules. A reasonable safety requirement in rules, for example, would offer VBAC patients an ultrasound for placental location. The use of medical technology when appropriate, and good practice, are key to great outcomes!

Q: Doesn’t licensure inherently decrease the number of people who can practice?A: Yes, BUT … Traditionally, licensure restricts practice. (And we certainly acknowledge the historical instances of licensure acts specifically designed to phase out midwives and their practice.) Licensure makes a circle: practitioners with licenses are inside, and everyone else is out – prohibited from practicing. But the context in which midwives practice turns that paradigm on its head, because physicians and nurses who attend births are already licensed. They are inside the circle; midwives are outside. By becoming licensed, midwives enter into the circle, thus widening it.
In addition, Michigan would like to be the state that turns the tide toward more consumer choice in birth. The two most recently licensed states, Maryland and Indiana, have suffered restrictive provisions. We won’t stand for that in Michigan. Our legislative champions support the rights of the individual and consumer freedom, as well as the freedom to safely practice a profession. Our sponsor, Rep. McBroom, has skin in the game: he and his four children were born at home. He is not willing to be party to a severely restrictive law.

Q: Does the bill require physician consultation, referral, or oversight?A: NO, except for a specification that such parameters be addressed in rules. (See Sec. 17117.) See Wisconsin’s rules for examples of acceptable rules on consultation and referral.

Q: Does the bill assign midwives prescriptive privileges?A: NO. Instead, the bill permits a licensed provider with prescriptive privileges (for example, a physician or Physician Assistant) to provide midwives with certain prescription medications. This arrangement is similar to one many midwives have now, but will include legal protection for both parties.

Q: Does the bill require midwives to secure informed consent?A: Yes. The purpose of licensure is to ensure the safety and welfare of the public; lawmakers want to be certain that clients are making informed decisions. This is a higher standard than physicians are subject to, but midwives welcome this standard as consistent with the Midwifery Model of Care. Assuring informed consent protects midwives as well as clients, in case of later disagreement or bad outcomes.

Q: How will licensure affect the relationship with hospitals for transfers?A: It should improve it. Because midwives will experience freedom from fear of repercussions by hospitals, licensure is expected to improve transfers. It may also accord clients more respectful treatment at hospitals and lessen the chances of home birth families being threatened with Child Protective Services.

Q: Won’t licensure make it a felony for unlicensed midwives to practice?
A: The unlicensed practice of a health profession is already a felony. Midwives may not acknowledge it, but they are all potentially in danger of being charged with the unauthorized practice of medicine. Upon being charged, midwives might successfully argue that midwifery is not a health profession, but courts have generally held the opposite. And, of course, the charge itself, the prosecutor’s investigation, and a court case are enough to severely – perhaps permanently – disrupt most midwives’ practice.

Q: Why can’t midwives just go on as they are?
A: Good midwives in Michigan are being investigated – despite appropriate care and good outcomes. We hear of more and more cases of home birth parents being reported to Child Protective Services after their births. We must make our state safer for our midwives and clients. Recent well-designed licensure acts in other states are shown to make both midwifery care and the profession more accessible and more affordable.
Thirty states authorize CPMs to practice; eleven more have legislation in progress. Passage of state licensure for home birth midwives is not only trending up nationally, but is being intensively discussed and planned by multiple organizations. US MERA decisions affect us on the state level whether we agree with them or not. Midwives must engage to regulate themselves, or someone else will do it for them.

Q: Will midwives be in danger of arrest once the bill passes?
A: Less so than now! In Indiana, one of the most criminalized states, the arrests stopped after licensure was enacted, even though no licenses have yet been issued.

Q: Who will write the regulations and which department will oversee licensure?
A: The Department of Licensing and Regulatory Affairs, in consultation with the Board of Midwifery. Passage of the licensure bill will establish a state midwifery board. Because the Michigan Constitution requires a profession’s licensing board to be composed of a majority of members of that profession, licensed midwives will play a major role in writing the regulations. Midwives can enlist the help of their supporters at that point to make sure the board understands what options consumers feel should be offered. (See above.)

Q: Will direct entry midwives with a certain amount of experience be ‘grandmothered in’?
A: Yes, with accommodations to meet certain standards.The state must first take certain steps before licensure is available. The bill will take effect 90 days after the governor’s signature. A Board of Midwifery will then be formed; a majority of it will be composed of midwives, as required by the Michigan Constitution’s clause on self-governance. The Department of Licensing and Regulatory Affairs, in consultation with the Board, in an open, public process, will promulgate rules addressing a range of practice issues, providing greater detail than is practical in a licensure statute. The procedure will differ for CPM and non-CPM DEMs:

A temporary license is anticipated for all current CPMs who did not graduate from a MEAC accredited program. Greater detail needs to be added to the bill on this issue. These CPMs, plus all midwives who earn the CPM before 2020 (see below), can become fully licensed by 1) fulfilling state administrative requirements outlined in the bill, and 2) completing the NARM Midwifery Bridge Certificate (MBC), which requires 50 Continuing Education Units (CEUs) in specific subjects. These same CEUs can simultaneously fulfill CPM renewal requirements.

The bill provides for licensing other (non-CPM) long-practicing midwives if 1) by 2020 they complete the NARM Experienced Midwife route, a process that is manageable in two years, as many current Michigan CPMs who became credentialed in this way can verify, and 2) obtain the NARM Midwifery Bridge Certificate, which requires 50 Continuing Education Units (CEUs) in specific subjects. These CEUs can also fulfill CPM renewal requirements.Non-CPM midwives may also hire a licensed CPM into their practice to provide the supervision otherwise provided under the bill and the Public Health Code. This arrangement provides excellent collegial support, by allowing midwives to assist each other, teach each other, and provide better midwifery care.After 2020, licensees must receive an education from a MEAC-accredited institution. This does not necessarily mean that there will be no more apprentice-trained midwives. MEAC and other midwife institutions are working to accommodate various methods of training that can also be MEAC-accredited. Midwives who received their CPMs by 2020 can qualify for licensure both before and after 2020 by earning the NARM MBC.

Q: Are there new educational requirements for midwives?
A: Yes, in accordance with new national standards. Seven U.S. midwifery organizations have come together in the US MERA (US Midwifery, Education & Association) group. Following several years of deliberation, MERA now specifies standards for midwife education. These standards represent the future direction of licensed midwifery in the U.S.; it is doubtful that licensure legislation will pass without inclusion of MERA language. The language requires that after 2020, midwives receive education accredited by MEAC(Midwifery Education Accreditation Council). NARM (North American Registry of Midwives) will continue to offer the PEP (Portfolio Evaluation Process) for previously licensed states without statutory MERA language. We are told that MEAC is working on a “Direct Assessment” option that may augment or replace PEP to the satisfaction of MERA language.

Because CPMs before 2020 are exempt from the MEAC education requirement, MERA has instituted a catch-up measure to bring these CPMs up to the standard of MEAC-accredited education. The Bridge Certificate, offered by NARM, consists of a number of continuing education units, overlapping the CEUs already required by NARM for CPM certification renewal.

Q: Won’t this bill force out competent midwives?
A: NO. Michigan needs more midwives, not fewer. Many Michigan midwives are struggling to keep up with the rapidly increasing demand for their services. It is in everyone’s interest to make sure that as many midwives as possible meet the new standards.
Wisconsin has issued 190 licenses since 2007, with 25 licenses issued the year they first became available. This number includes student licenses. There have also been a few disciplinary actions, but two censured midwives were able to continue practicing while they complied with the disciplinary recommendations of the Board.
The Michigan bill also features two very robust licensure exceptions for religious midwives.

Q: Will licensed midwives be required to ‘turn in’ unlicensed midwives? I heard this happened in Pennsylvania.
A: NO. This is not the case in Pennsylvania, a state that does not license midwives, but is the case in Florida and at least one other state. There is no intention of making this law in Michigan; it was certainly not included in past bills. As stated above, once the licensure bill passes, it will be the task of midwives and consumers to advocate for acceptable regulations.

Q: How much will a license cost?
A: The initial cost of a license is set at $450, with an annual renewal fee of $200. Michigan law requires all licensure regimes to pay for themselves through fees; because there are so few midwives compared to other health care professions, licensure fees were initially determined to be in the thousands of dollars! The state licensing agency, the Department of Licensing and Regulatory Affairs (LARA), worked hard to reduce fees to the amounts listed above.
License fees vary widely from state to state and are partially determined by the state’s costs in assessing midwives’ qualifications. Basing licensure on the CPM credential should keep the cost of licenses low: because the North American Registry of Midwives assesses CPMs’ qualifications, the state need not assume that cost; the effect is to make licenses considerably less expensive. In addition, licensure standards are then sure to follow the midwifery model of care rather than a standard created by state legislators. Older laws in other states, especially laws that pre-date the CPM credential, have tended to be more costly than programs enacted in the last decade.
Below is the projected impact of licensure fees per client, assuming that midwives wish to amortize the cost of the license by the end of the first year:

$650 cost of licensure divided by 25 clients per year = $26 per year per

$650 cost of licensure divided by 60 clients per year = $10.83 per year per

For those midwives considering also the cost of the CPM certification, an estimated $2000 amortized over only 1 year = $80 per client for a small practice (25 clients), or $33 per client for a 60-client caseload.
Wisconsin’s licensure act was passed in 2006; licenses began to be issued in 2007. As of 2009, the state’s home birth rate was over 1.5% of all births. In 2013, the rate had risen to just under 2%. (We have been unable to determine whether this figure includes birth center births, but as licensed midwives staff the majority of Wisconsin birth centers are, it is less critical to distinguish between home and birth center births to assessing home birth rates.)
In contrast, Michigan’s home birth rate is still under 1%.
Midwife fees for home births in Wisconsin are comparable with Michigan’s. To date, licensure in Wisconsin has not increased client costs.

Q: Will the bill guarantee midwives insurance reimbursement?
A: Unfortunately, no. Like other Michigan licensure bills passed in the last 20 years, HB 4598 specifically states that it does not create a right to new or additional third party reimbursement. Nevertheless, insurance reimbursement is highly unlikely for unlicensed providers. Therefore, licensure is the first step in securing insurance reimbursement. Insurance companies usually require a license number to cover a midwife’s home birth fees.
In addition, approximately 15 states now authorize Medicaid to pay for out-of-hospital births. In 2007, Washington State estimated that it saved $2,700,000 per two-year cycle by having Medicaid cover out-of-hospital births attended by licensed midwives. If Michigan follows Washington State’s lead, this licensure act will drive taxpayer costs down.
If federal regulations are promulgated for the Affordable Care Act’s Provider Non-Discrimination Clause (the Harkin Amendment), private insurance companies will not be permitted to discriminate against a class of providers licensed in their state.

Q: Will licensure help midwifery students?
A: Yes! Many midwives have spent time and energy in training students, only to have them leave for other states. Given a choice, many new midwives would just as soon not set up businesses in a state where practicing may get them arrested. In addition, licensure may spur new schools of midwifery to be established in Michigan, offering more options for education. When CPMs are licensed, government education loans become available to them, as do loan forgiveness programs for midwives willing to practice in underserved areas.

Q: Will the bill do anything else for midwives?
A: Yes! Midwives who wish to volunteer their time in local clinics, other states (think Hurricane Katrina!), or abroad (mission work), will find that many governments require them to be licensed in their own state in order to work elsewhere. Licensure will open up opportunities for this work!

Q: Why can’t we see what the final law’s wording will look like? Why should I support it before I know exactly what it will say?
A: No one knows what the final wording will be! The legislative process is a lengthy one; most bills are revised as they move through the process. FoMM does not enjoy ultimate control over the contents of the bill, but rather makes recommendations to the sponsor, other legislators, interest groups, and consumers. The best way to track what provisions are included–or not–in a current version of the bill is to check the FoMM public Facebook page.

MORE RESOURCES

Because the bill is modeled on Wisconsin’s midwife licensure act, here are links to Wisconsin’s statutes and rules.

California recently enacted legislation to allow Licensed Midwives (LMs) to provide “comprehensive perinatal services” under Medi-Cal, the California Medicaid program. It is not possible in Michigan to include insurance provisions in a licensure bill; we can only hope that once HB 4598 is passed, either the Administration will adopt policies making this possible, or the Legislature will move to enact legislation similar to California’s.

Want to see a summary of Michigan’s efforts? Check out our state profile on the Big Push for Midwives site.